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Conventional treatment of male infertility in the past used a wide array of medicines to try to improve a low sperm count in the infertile man. These included :

Gonadotropin injections ( HMG and HCG)

These hormonal injections of gonadotropins are only useful in stimulating sperm production in azoospermic men ( zero sperm count) who have hypogonadotropic hypogonadism (men with low FSH and LH levels, because of hypothalamic or pituitary malfunction), but this is a very rare condition. In these men, treatment often takes many months to restore the sperm quality to fertile levels. Combination treatment is required, with HCG to stimulate testosterone production; and HMG to stimulate sperm production. Initially, the man takes HCG injections thrice a week for about 6 months. This normally causes the size of the testes to increase and the testosterone to reach normal levels. HMG injections are then added. These can be mixed with the HCG and are also given thrice a week. Once sperm production has been achieved, the HMG can be stopped; and HCG treatment continued alone. While sperm counts achieved are usually low (less than 10 million per ml), a successful pregnancy can be achieved in 50 % of correctly diagnosed patients.

Unfortunately, these expensive injections are often misused as "empiric" therapy in men with low sperm counts - with extremely disappointing results. Since the vast majority of infertile males have normal levels of these hormones, unfortunately, giving them additional injections does not help to boost their sperm production. The reason this is confusing for many men is that the very same injections are given to their wives to make them grow more eggs - so why can't the injections be used to make them produce more sperm ? While this is a logical argument, which is why doctors will try out these injections, unfortunately they simply do not work, so using them is just a waste of time, money and energy.

Bromocryptine

As in the female, this is used to lower unusually elevated levels of prolactin. However , this is a very rare problem in infertile men; and most men with high levels of prolactin are also impotent.

Testosterone

This is given to suppress sperm production in the hope that when medication is stopped (usually after 5-6 months), then the sperm production will "rebound " to higher levels than originally (testosterone rebound). This form of treatment is now seldom used as it may further impair fertility and is hazardous. Testosterone is also be used for the treatment of impotence or diminished libido when blood testosterone levels are low. Testosterone is available as an oily injection and is given intramuscularly, usually once a week. Oral preparations are also available now, but these are more expensive and may not be as effective.

Clomiphene This is the most commonly prescribed medicine for infertile men - and the one which is most widely misused. Its use is largely empirical and very controversial as the results are not predictable. This is usually prescribed as a 25 mg tablet, to be taken once a day, for 25 days per month, for a course of 3 to 6 months. It acts by increasing the levels of FSH and LH, which stimulate the testes to produce testosterone and sperm. The group of men who seem to benefit the most from clomiphene have low sperm counts, with low or low-normal gonadotropin levels. However, while clomiphene may increase sperm counts in selected men, it hasn't been proven effective in increasing pregnancy rates.

Antibiotics Just as in the female, antibiotics can resolve a chronic infection in the reproductive tract in the male. However, there is no evidence that treating pus cells in the semen helps to improve male fertility.

Vitamins and antioxidants Again, there is no evidence that they work , but since they "do no harm", many doctors will prescribe them - and many patients will take them. Popular once include Vitamin E and Vitamin C, along with arginine and zinc.

Herbal treatment, ayurvedic treatment and other magic potions Everyone seems to have a "magic potion" to cure low sperm counts - the trouble is that no one has ever proven that anything works. Take all claims with a liberal pinch of salt !

Many men will observe that their sperm count increases after taking these medicines, and they get very excited when this happens. However, do remember that sperm counts fluctuate all the time - and often the increase is inspite of the medicines, not because of it . In any case, a sperm count is not like a bank account that you should get excited when it increases ! The end-point is not an increase in the sperm count or motility - it's a baby ! While some of these medicines may improve sperm counts in some men on some occasions, double blind clinical trials have shown they do not help to improve pregnancy rates. This criticism is also true for the currently fashionable Proxeed, which is being marketed very aggressively and cleverly in the USA.

The problem with the medical treatment of a low sperm count is that for most people it simply doesn't work. After all, if the reason for a low sperm count is a microdeletion on the Y-chromosome, then how can medication help ? The very fact that there are so many ways of "treating" a low sperm count itself suggests that there is no effective method available. This is the sad state of affairs today and much needs to be learnt about the causes of poor production of sperm before we can find effective methods of treating it.

However, patients want treatment, so there is pressure on the doctor to prescribe, even if he knows the therapy may not be helpful . When most patients go to a doctor, they expect that the doctor will prescribe a medicine and treat their problem. Since most people still believe there is a "pill for every ill", they expect that the doctor will give them a medicine ( or an injection) which will increase their sperm count. No patient ever wants to hear the truth that there is really no effective treatment available today for increasing the sperm count.

Since most doctors know this, they are pressurised into prescribing medicines for these patients, because they do not want the patient to be unhappy with them. They are worried that if they do not fulfill the patient's expectation of a prescription, the patient will desert them, and go elsewhere, which is why they often do not tell the patient the complete truth. The doctor also remembers the occasional anecdotal successes (who come back for followup , while the others desert the doctor and are lost to followup) is why patients with low sperm counts are put on every treatment imaginable - with little rational basis - Vitamin E, Vitamin C, high-protein diets, hoemeopathic pills and ayurvedic churans. However, the very fact that there are hundreds of medicines itself proves that there is no medicine which works !

Many doctors justify their prescriptions by saying - " Anyway it can't hurt - and in any case, what else can we do? " However, this attitude can be positively harmful. It wastes time, during which the wife gets older, and her fertility potential decreases. Patients are unhappy when there is no improvement in the sperm count and lose confidence in doctors. It also stops the patient from exploring effective modes of alternative therapy - such as In Vitro Fertilization and ICSI . Today empiric therapy should be criticised unless it is used as a short term therapeutic trial with a defined end-point.

A word of warning. Medical treatment for male infertility does not have a high success rate and has unpleasant side effects, so don't take it unless your doctor explains his rationale. The treatment is best considered "experimental" and can be tried as a therapeutic trial. Make sure, however, that semen is examined for improvement after three months and then decide whether you want to press on regardless.

It is worth emphasising how small the list for male infertility treatment is - especially as compared to female treatment. This simply reflects our ignorance about male infertility - we know very little about what causes it, and our knowledge about how to treat it is even more pitiable !